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- HHS Releases Patient-Provider Dispute Resolution Guidance from No Surprises Act
On January 4, the Department of Health of Human Services (HHS) released the No Surprises Act Patient-Provider Dispute Resolution guidance, which helps providers understand what information to include for the good-faith estimates. The CAP worked closely with Congress during the development of the No Surprises Act and advocated for patient protections, but has continually expressed the serious risks for patient harm and substantial difficulty in determining the cost of pathology services in advance of services conducted by the pathologist.
While the No Surprises Act established an independent dispute resolution process for payment disputes between plans and providers, it also offers new dispute resolution opportunities for uninsured or self-pay individuals. This "Patient-Provider Dispute Resolution” process is available for uninsured or self-pay individuals who get a bill from a provider substantially in excess of the expected charges on the good-faith estimate (more than $400). The process uses a third-party arbitrator to review a patient’s good-faith estimate, final bill, and other information submitted by your provider or facility to determine a payment amount. Effective January 1, providers, facilities, and providers of air ambulance services will need to give an uninsured individual a good-faith estimate of expected charges after an item or service is scheduled or upon request. Important for pathology, from January 1, 2022, through December 31, 2022, the HHS will exercise its enforcement discretion in situations where a good-faith estimate provided to an uninsured (or self-pay) individual does not include expected charges from other providers and facilities that are involved in the individual’s care.
The HHS has related guidance for Providers and Facilities, Selected Dispute Resolution Entity, Uninsured or (Self-Pay) Individuals, and guidance on the Administrative Fee.